The Shift to Payment Accountability®: An Enterprise Approach to Healthcare Payment Integrity

April 29, 2024

HealthEdge

Health plans are facing unprecedented challenges in accurately pricing claims due to a growing number of value-based payments and government regulatory requirements. As providers’ expectations for more efficient and accurate payments continue to rise, health plan leaders are turning to modern technology for help. In the past, health plans used a traditional approach to solving these challenges. They relied on multiple business units and stacked third-party claims editing solutions—which resulted in a fractured approach that focused solely on measuring a percentage of recovered savings downstream.

The future of payment integrity is shifting towards Payment Accountability®, an enterprise-wide approach that brings together different business units to increase focus on measuring cost avoidance instead of just recovery. Payment accountability emphasizes creating transparency to address root cause inaccuracies so that payers can pay claims accurately, quickly, and comprehensively the first time.

Industry experts claim that this enterprise-wide approach can reduce medical expenses by 10% or more, with the potential for significant reductions in administrative expenses. An enterprise approach to claims adjudication can shift processes upstream, solve root-cause issues, increase accuracy, and reduce provider abrasion.

The Source Approach to Payment Accountability

HealthEdge Source™ (Source) was specifically designed and intentionally built to enable payers to allow health plans to insource more functionality, derive valuable analytics, and increase transparency and interoperability.

The Source platform, to meet evolving market demands, is focused on the following core areas:

Real-time integration expansion: Seamless integrations with third party solutions that expand payment integrity and reimbursement offerings and reduce the administrative burden on clients using multiple vendors.
- Continued content expansion: To deliver added automation, savings, and accuracy, including additional Medicaid, Medicare, Cost Containment, and other specialty edits and pricers.
- Improved accuracy: By including additional validating datasets such as prescriptions, medical records, and others.
- Adoption of AI/ML technologies: To automate and/or assist manual and tedious workflows.
Efficient workflow and best-in-class user experience: Through self-service tools like policy creation, implementation, and management.
Creating insights for data-driven decisions.

But the team doesn’t stop there. Our product investment strategy includes a multi-year roadmap focused on enhancing the content, features, and technology to drive continuous improvement in the solutions we deliver. We’re currently piloting an AI-enabled chat bot that allows users to type questions in natural language regarding the Source edits, pricers, functionality, and other capabilities. This results in quick and accurate responses, freeing auditors or provider relations team members from scouring through multiple user guides, worksheets, and other materials. The chatbot can provide the necessary information in seconds.

Additionally, Source is streamlining the process of managing configuration by utilizing APIs to create, manage, and publish edit changes to production. This process reduces the need for manual user intervention, allowing the payment integrity and configuration team members to focus on other critical business tasks.

A Guiding Hand from the Payment Integrity Experts

Source experts are available to participate in a Payment Integrity Health Check as part of the implementation process. This helps our team gain a better understanding of your current processes, data, and internal expertise so that we can work together efficiently and provide a solution that enhances your health plan’s strengths and aligns with the long-term payment integrity goals. Source experts will also work with our customers continually after go-live, to review data and identify areas that can add value to your payment integrity program.

Post-implementation, Source maintains close partnerships with our clients. We gather feedback and input on our product roadmap in many ways, such as conducting 1:1 user research and design sessions with the product and engineering teams, monthly user groups, semi-annual customer advisory boards, regulatory steering committees, bi-annual virtual customer events, and annual client conferences.

From Payment Integrity to Payment Accountability

At Source, our solution aims to redefine payment integrity by shifting the industry from a black box to an open-book approach. Unlike traditional payment integrity solutions that often operate retrospectively and give limited intelligence to health plans, Source is designed to deliver transparency in editing solutions. Our goal is to empower payers with technology that enables them to gain control of their IT ecosystems, address root-cause issues, and reduce waste in the healthcare system.

Source accomplishes this differentiation by providing the following unique features:

The ability to configure contract reimbursement terms, edit and price claims, and run analytics in a single call to Source.
Extensive editing and pricing content libraries that are out of the box and always up-to-date and accurate through our two-week update cycle.
Configurable and customizable edits to make pre-payment claim decisions based on a health plan’s intellectual property.
Real-time analytics to monitor utilization and financial impacts of edits prior to enabling their impact in the live adjudication workflow.
Claims pricing based on negotiated fee schedules, including CMS and Medicaid methodologies, to ensure edits and reimbursement are accurate prior to adjudicating the claim.
Continuous member claims history analysis by the Source team to recommend new edits that solve recurring post-payment issues.
Integrated third-party content within the solution to improve accuracy, promote higher and faster automation, simplify workflows and vendor contracting, and keep all data in a single location.